Many states require direct access to OB/GYN doctors on the theory that it will improve maternal and infant health. However, the current evidence demonstrates that direct access laws do not improve maternal or child health.
The advent of managed care has presented barriers to direct access to specialist care for many patients while helping to contrain overutilization of health care services. Some of this is warranted; primary care physicians should be involved prior to patients visiting many types of specialists. However, for women, access to obstetrician/gynecologists (OB/GYNs) is viewed by most to be a form of primary care. Therefore, many state legislatures have implemented laws requiring insurers to allow access to OB/GYNs without requiring referrals from a woman’s primary care physician.
In favor of direct access mandates, the hypothesis exists that by improving access to OB/GYNs a positive impact on maternal and child health would follow. By contrast, the potential negatives of any health insurance mandate would be the added cost spread across all policyholders. We have reviewed other studies discussing mandated health benefits.
This study examines data from the Natality Data File and the Pregnancy Assessment and Monitoring Survey from the mid-1990s through the early 2000s assessing the impact of direct-access laws on various aspects of maternal and child health. The outcomes discussed include maternal alcohol and tobacco use, prenatal care utilization, and infant health outcomes such as prematurity and low birth weight.
State mandates for direct access to OB/GYNs began in 1995 such that currently 42 states have such legislation in action. Statistical analysis of the data reveals that direct access laws do not significantly affect maternal behaviors such as tobacco or alcohol use. Likewise, there is no effect on early initiation of prenatal care in states with direct access laws. When examining the data for effects of infant health, there is in fact a statistically significant reduction in prematurity; however, the magnitude of this effect is merely one-tenth of one percentage point. The baseline rate of prematurity as measured in this study is approximately 11.3 percent, highlighting how minimal a change of one-tenth of one percent might be. No significant effect on low birthweight was noted.
In the end, not all insurance policies (and therefore not all women) are subject to direct access mandates. Employers that self-insure (ERISA plans) and Medicaid plans may not be held to that same state mandates.
Health insurance mandates must balance the benefits of supplying a clinical service with the added costs that will be applied to the entire insured population. In the case of direct access to OB/GYNs, this and prior studies indicate that maternal and child health measures are not significantly improved in states that require direct access to OB/GYNs.
The lack of effectiveness of these laws may be partly due to the fact that a portion of women in each state possess insurance plans not subject state mandates (these include ERISA plans and federal insurance plans). However, it is feasible that in reality, these laws do not translate into better health outcomes.
After the passage of the Affordable Care Act (Section 2719A), direct access to OB/GYNs will be mandated for health insurers. The evidence suggests that this may not prove to benefit health and the authors of the above study recommend alternative policies to achieve improved maternal and child health. If the goal of policy makers is simply to allow women to be able to see an obstertrician/gynecologist without first having to visit a primary care physician, that goal will have been achieved.
Policy makers must remain vigilant to balance the costs of mandates with the clinical benefit expected from them.
Cedric Dark, MD, MPH